00050215CITY OF CUPERTINO
BUILDING DIVISION,
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"CoNF0RMA.IONf1` *
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PERMIT
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RUILDINGADDRESS:
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PERMITNO. Q..��. N
LPF9
GQLIjMBleJS
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21450
OWNER'S NAME: n'
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APPLICATION SUIW650215
PHONE: _
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SANITARY NO.
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05400'60
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1T/ G'IOO ,.
ARCHITECT/ENGINEER.
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
x' LICENSED CONTRAC'rOR'SDECLARATION
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I, hereby affirm that I nd m leeirwunde........ ions of Chapter 9 (e narking
t with Section 7000),fD i ofIh Business .,ad P f: Cd dmyl ew
i. in full f If
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ct
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ARCHITECTS DECLARATION,
' 1 andc,oaralary,lic,0hill bo us d a: puble records
Livereed Prf si al
oWNCRBUILDLRDECLARANON
FURNACEiCHANGOUT,' INSTALL A�6%LINIT
I hereby affirm that 1 car exempt fon the Contractor's License Law for the
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following maenn. (Section 7031.5, Business and Prolvieier, Code: Any dty or county
which requires a permitro coinsure, alter, impnrve, deme, ish, or repair any-rtmalnre
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poor r0it, isv.. are, ale requires the up,la,mr for such permit n, File usigned lalement
Sq. Ft. Floor Area -
Valuation .
that he is licensed.ursaam a..the .ravlxi.nsof(he Coal .amof, License Law(Cha.ter 9
(comnicndng with Smainn70IXR of Divi.inn3 of the Runinosn and Dmfesni,ins Cnde)
..phot he s exennpt Ommfrom and the basis Fier the alleged exemption. Any violation
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non 7(13LS by an cnm for$ ponnit suhjwas the appliunno a civil nearly
Wamsereman five aincLedaouarx (anon),
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AP,N "Number
� Occupancy. ype
°I, an owner ofine pm.erty,er my employee, will, wages as their so ie emopensution.
will do the work, tend the structure is not intended or offered for sale (Sec. 70,LL-
Busiaess and Professions Cade: The Contractors License Law docs net apply in. an
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e'mred Inspections
of its, of ,.,my Who milds car improve, Omrnm, and who does such work himself
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o through his own employees provided that such ver ntvetneol are not intended or
for sale. IL however, the building tib impmof n sold one year of.
coffinedomple Prov
will have the burden of proving that he did not build or
he
improve for arowne.-budder
improve for puryouc ar cele,).
ol,axownet ofthe prupery,amexclusively contracting with licensed contractonm
204 — UNDERFLOOR FRAME .
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chred the project (See. 7044, Bmiress and Pr..fissions Cade:) The Confront's
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License Law does nm apply to an owner of property who builds or improves thereon.
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and who contracts for anon projects with a cannacter(o licensed parsoantan the
303 — , ROUGH MECHANICAL '
Confortar, License Law. I
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° I ma rxerept order Ser. ,B& P C for this reason
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304.— ROUGH ELECTRICAL
Owner iter
505 — FINAL ELECTRICAL
WORKER'S COMPENSATION DECLARATION'. -
507 — FINAL PLUMBING .
InerebyalRnatmderpenanyofperjuryone of the fauowingdelar,dons:
— FINAL MECHANICAL
° I have and will armantaint or Certificate of Consent to self -insure for Worker's
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Compensation. as .mvidw ret by Section 1700 61' the Lanor, Code. for tine
514 '- FINALWORKS '
performance of the work for Which this permit is issued.
,PUBLIC-
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hoveand will maintain Worker's Compensation Imumnca as required by Seetion
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J700 of din O'lwr Code, for the performance of the work f which this pe mit is
issued' M ' Workers pens nI nncecav dPt11- h
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Gar. ally s
CERTIFICATION OF EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE'
'(This section need not ihe completed if the permit is for one hundred dollars
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W00)..rless.)
1 certify that in the performance of the work for which this permit is issued, I
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shall not employ any person in any manner so as to become sunint to the Workers'
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Compensation Laws of California Des
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Applicant
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NOTICE TO APPLICANT: If, after making this Certificate of Exemptimn, you should
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he,,,. subject at the Workers Ctnaps,ma.... n provie ons arm, Labor Cads, you must
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forthwith comply with such freemen,, or this permit shall he deemed invoked.
" CONST RUCTION LENDING AGENCY
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Thereby affirm that there is a constriction lording agency for the performance.
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of the work for which this permit is Issued (Sea 3097, Civ. C.)
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Lender's Name -+
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Lender's Address'
1 eenil'y that Phave mud this application and state dal the above inf..mention Is
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e..rrern 1 agree to comply with all city and .arty ordiminsea and state laws inluda,
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m hulldiog eonswmlos end hereby nuthndee m,neserietwes rnhii city to enter upon
the above mentioned p pe t> for imCptvdio.pardev,,
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(We)ago,, ,, save, indemnify aI oce, h"mless the City of Capshila-da'nt
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liabililles,judgmarts. viests and expenses which may inmy wayaccrueagiest said
City quince t I th bmining of th'. permit,
APPLICANT UNIT ANDSAND 'ILL COMPLY WITH ALL NON.P9INT
SOURCE TIO
Issued by:"C� Date -S`�3/ C)
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Signature Appllcan ( mructor " I v¢
Re roofs - -
HA ROOFS MATERIALS DISCLOSURE
Will the applanot... panic building..mtpum store or handle hamrdous material`
Type hoof + +
as defined by the Cupcdina Municipal Code, Chapter 9"12: and (he livelN rind Safety
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Code, Section 25532(a)l' n
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All roofs shall be inspected prior to any roofing material being installed.
Will lheapplicumer future bailiingoccaprat one egntiPt»cnt or,devices which•
If a roof is installed without first obtaining -an, inspection, I agree to remove'
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emit he ... o.,air.maminants as attired hytfie Bay Area Air Quality Management
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all new materials for inspection. Applicant understands and will. comply.with
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all non -point source regulations.
1 have read the amandous materials nyuirements under Chapter 6,95 'of the
California Health & Safety Cale, Sections 25505, 25533 and 25534" l understand thus
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if the haddia,me, hot currentlyh a tenant, that it iy respearbility to ready the
pa a f@ ey t h 1 must h t .' m is f CentOc
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Signature of Applicant Date
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All roof coverings to be Class "B" or better -
QW tit authnrir f Y Ua
sibs OFFICE t